Dosimetry Application Form (UW Health) Dosimetry Application Form UW Health Section 1: Personal IdentificationI will work with* Radioactive Materials X-Ray Producing Machines UW Health Radiation Safety Dosimetry Training DateFor training: 1. Log into U-Connect, go to “Quick Links” 2. Go to “U-Learn” under “General Links” 3. Click the magnifying glass in the upper right corner 4. Search for “UW001409” 5. Register and Launch “Radiation Safety-Dosimetry” 6. Take and pass the short quiz at the end of the course Date Taken: MM slash DD slash YYYY Access Community Health Center Training DateFor training: 1. Take the mandatory training: Access Community Health Center Dosimetry Training 2. Confirm date below Date Taken: MM slash DD slash YYYY Name* First Middle Last Gender*FemaleMaleDate of Birth* MM slash DD slash YYYY Department* Email* Phone*Section 2: Employment InformationI am a:* Full-Time Employee Temporary Employee Student Employment Start Date* MM slash DD slash YYYY Employment End DateIf Applicable MM slash DD slash YYYY I was previously badged at:*Please check all that apply. UW-Madison UW Hospital UW Medical Foundation None of these; I was not previously badged Other Previously badged at Other - please explain* Other employment involving radiation exposure:*Are you currently or have previously worked with radioactive material or radiation producing machines and have been monitored for radiation exposure? Yes, but not within this calendar year Yes, within this calendar year (copy & paste: https://ehs.wisc.edu/request-for-previous-dose-history-form/ and fill this form out after you submit the application) No Department employed in:* Access Community Health Center Anesthesiology Cardiology Family Medicine GI / Urology Nursing Oncology Orthopedics Pulmonary Radiology Surgery / Operating Rooms Access Community Health Center* ACC - Access Comm Health Center - Tammy Quall Anesthesiology* ANT - Anesthesiologists - Marie Hendricks Cardiology* CAL - Cardiovascular Laboratory (Cath Lab) - Nicole Heininger CF – Cardiology Fellows – Nicole Heininger EC - Electrocardiography - Suzanne Klingaman SON - ECHO/Vascular Lab - Chris Busse Family Medicine* BLC - Belleville Family Medicine - Erica Dill FM - Wingra Family Medicine - Erica Dill FP1 - Family Practice Northeast - Erica Dill FP2 - Family Practice Verona - Elena Prozorova GF - Generations Fertility Care Clinic - Barb Schulz GI / Urology* GU1 - GI & Urology Clinic - Joy Schluckebier GU3 - GI & Bronchoscopy APC - Sarah Baumann MGI - Meriter GI Physicians – Amy Tatro Nursing* ACH - American Family Children’s Hospital (P4) - Lisa Keller CRU - Clinical Research Unit - Tammy Kiger F66 - F66 Nursing Ward - Jayne McPhail NR1 - Nursing Services - Christine Spier Oncology* CCU - Cancer Clinic Chemo Unit (Lutathera) - Kendra O’Connell JCC - Johnson Creek Cancer Center - Dawn Klecker RTH - Human Oncology (Radiotherapy) - Jami Wood Orthopedics* OT - Orthopedics - Beth Lalor RH1 - Rehab – General Services - Samantha Jackson Pulmonary* MPU – Meriter Pulmonary – Amy Tatro Radiology* CT - Computed Tomography (CT) - Donna Juno ESC - East Clinic Radiology Department - Carrie Hamielic DVC - Interventional Radiology Tech's - Jaime Nodolf MAC - Mammography (Breast Center) - Johannah Kereven MP2 - Medical Physics (PET Tracers) - Christine Jaskowiak MP5 - Medical Physics (Molecular Imaging) - Christine Jaskowiak NM - Nuclear Medicine (University Hospital) - Rhonda Denu TNM - Nuclear Medicine (The American Center) - Chris Goetsch RD2 - Radiology (Faculty/Fellows) - Holly Jackson RD3 - Radiology (Residents) - Maggi Schrader RD4 - Radiology (UWHC Diagnostic Radiology) - Brett Wehmeyer RD6 - Radiology (UWHC Clinics) - Mary Gehin RT1 - Radiologic Technology - Renee Richardson TAC - The American Center (Imaging / Diagnostics) - Tracy Ellis WSC - West Side Clinic (Diagnostic Radiology) - Karmen Shoys WS1 - West Side Clinic (Bone Mineral Density) - Brenda McCarney Community Radiologists Interventional Radiologists Community Radiologists* FTA - Fort Atkinson Healthcare - Cathy Hovel MAQ - Mauston/ Mile Bluff - Felicia Abbott MEQ - Meriter Hospital - Amy Tatro RHQ - Richland Center Hospital - Jeremy Pauls TA2 - The American Center - Tracy Ellis UF0 – UWMF Radiology (Medical Imaging/Nuclear Medicine – chest) – Kari Pulfer UF1 - UWMF Radiology (Medical Imaging - collar) - Kari Pulfer Interventional Radiologists* CAL - Cardiovascular Lab: Cath Lab - Nicole Heininger MAM - Mauston/Mile Bluff - Felicia Abbott MEM - Meriter Hospital - Amy Tatro RD1 - Radiology (University Hospital) - Holly Jackson VAM - VA Hospital - Diane Meranda VS- Vascular Surgery - Jacqui Huebner Surgery / Operating Rooms* CHS - American Family Children’s Hospital Surgery - Monica Skeat MOR - Meriter OR Physicians – Amy Tatro OR - Operating Rooms - Peripheral Vascular – UWHC - Beth Phillips ORO - Operating Rooms – Orthopedics - Aaron Signer OS - Outpatient Surgery - Ashley Ring SU3 - Surgery (Voice & Swallowing) - Nichole Rauch TSC - Transformations Surgery Center - Erin Hernandez UF2 - Madison Surgery Center - Tammie Schroeder VS - Vascular Surgery - Jacqui Huebner By Signing this Form, I Attest to the Following: I will exchange my badge on time and return it to my badge group leader upon resignation. I certify that the information on this application is correct and complete, to the best of my knowledge. According to DHS 157.22(5), I hereby request and authorize my previous employer(s) to release my dosimetry records. Employee Signature* Signature Date* MM slash DD slash YYYY Supervisor Name* First Last Supervisor Signature* Note: Names may be typed into the signature field. Inclusion of the signature or typed name of a UWHC supervisor indicates their knowledge of, and consent to, the submission of this form.